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Home My WebLink AboutWiring Permit - Permits #12606-1 - 164 KINGSTON STREET 8/19/2015 $,9 �� ` c Date..... ......e.. p►OR7F/ 3� •"',.';,tiooL TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING 8g4CHUg0 ; ........................................................... This certifies that .......... ..::. ............... has permission to perform ................................................ .... y ..... .. ........ A A J.. wiringin the building of........ r ..: .................................................................. North Andoverat ( �� R .., Mass. et f � 4 Fee.... .. . ........Lic. No. ................. .... I : .rG.?. ........ .; ELECTRICAL INSPECTOR Check#k � ,�' C onimonweaCfh ol�aescuhct�e Official Use Only i _: Perniit No. �eParr`me�iE o�.}ire�erviceS , BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev, 1/07) (leave blank)' APP❑CA N FOR P ERNT TO PERFORM EP ECTRGCAL WOO All work to'be performed in accordance with the Massachusetts Electrical Code(IvfEC),527 CMR 12,00 (PLEASE PRI1dT IN INK OR TYPE ALL IIJFORMATION) Date: `1 , City or Town of: ft�en do r To the Inspector of Wires: By this application the undersiggives notice of his or her intention to perform the electrical work described below. Locadon(Street&Number) j K!A 4 � oo � ti Owner'or Tenant }} tP�l� I yy Telephone No,7 ; 6lc 'ner's Address 6 Fed ' Y f )el AA t e ' Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Q es d�s�G aL Utility Authorization Io, Existing Service /V e Amps /'�)o / q.0 Volts Overhead ❑ Undgrd No,of Meters C New Service 100 Amps ! 4b Volts Overhead ❑ Undgrd No, of meters € Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work; ae. o Com letion ofthe follo 1n fable m be waived b the Ins ector of Wires, No, of Recessed Luminaires No. of Ceil,-Susp. (paddle)Fans No, of Total Transformers KVA No, ELurmninaire Outlets No, of Hot Tubs Generators KVA No, ires Swimming Pool Above ❑ In- ❑ o. o mergency ig trng rnd, rnd. Batts Units No, of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No, of'Switches No, of Gas Burners No. of Detection and Initiatfna Devices No. of Ranges No.,of Air Cond, Total No. of Alerting Devices Tons g No. of Waste Disposers Heat Pump Number.To.ns...., KW No, of Self-Contained Totals: ........ "' Detection/Alerting Devices _ No,of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No, of Dryers Heating Appliances KW Security Systems:* No. of Water No,of Devices or Equivalent KW No, of Ito, of Data Wiring: Heaters . Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications 'Wiring: No.of Devices or Equivalent OTHER: ��(y Attach additional detail if desired, or as required by the Inspector of wires. Estimated Value of Electrical Work: id o _ (When required by municipal policy.) Work to Start; a S Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C ERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liabil' insurance including"completed operation"coverage or its substantial equivalent, The undersigned certifies that such eo rage is in force, and has exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains penalties gof per ury, that the information.on this application is true and complete, AlRM NAME: T'�� t ( hCi�� A t? �G4 � l e L1C, N'O,:_ a ' � Licensee: cAA ,qk r ��,4 C Cf� Signature LIC, NO.:f , 0. (Ifapplicabl me pt"in the I' we nuinber line.) Bus. TeL No,: • `" 6,_ Address: Y 1 PW Q Q f' 5 `� Alt, Tel, No,: r�7 *Per M.G.L. c, 147, s,57-61 security work requi es Department offPublic Safety"S"License: Lic,No, OWNER'S INSURANCE WAIVER; I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement, I am the(check one) El owner [I owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 1`S(FJ` e v ` O , V `1 M\ yl The Commonwealth of Massa.chusetts Department of IndustrialAccidents I Congress Street;Suite 100 .Boston,AM 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY.'. Applicant Information `` Please Print Le gib Name (Business/Organization/Individual): �t � � �l`J ) e& E,.Co¢ Address: �IC�S�1�e1it�Qy�� "1� -�w$�1t > � l C) Li�� City/State/Zip: �,J �l$hone#: � ' 3 Arey an employer?Check the appropriat box: Type of project(required): 1.L1rJ 1 aam a employer with__employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I lectrical repairs Or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no,employees.[No workers'comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees.'Below is the polipcy, and job site information. (9 GA�tiV$f�i� �� U L�� E �j 0 Insurance Company Name: t ow\ y. ', " Policy#or Self-ins.Lie.#: C tl Lv "Q Expiration Date: <40 ^ Job Site Address: tic - !a City/State/Zip: !VEr6' A 11o4faYC�4�AA+ 0 1 9 Attach a copy of the workers' compensation policy declaration.page(showing the policy number and expiratidn date). Failure to secure coverage as required under MGL o. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify t nder the ains,aand penalties ofperjuiy that the information provideed above is trite and correct. Signature I(�K trl °��i �I a Date- M Phone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other " Phone#: Contact Person: I 1 n i RECr°tTn MAS� R � 7f 1 C l AN d M��"F1U�N MA b;1844 17a t �a�g2A r it— _ e e eooz�i•taAaa etoz•cb ad 6d'�(y�y�,Q 101�•668�0 tlNt'N3fiM�� `' �^�.-�j y�� .j �N,b"f f1C7�IN�`IEItl g f G � L3 5✓ a��wnt+rrb�NON �E¢OZ MCI ee